Intractable conflicts over end-of-life decisions: A descriptive and ethical analysis of French case-law

Abstract

Context: In European and Anglo-Saxon countries, life-sustaining treatment (LST) limitation decisions precede more than 80% of ICU deaths. However, there is now increasing evidence of disagreement and conflict between clinical teams and family members over LST limitation decisions. In some cases, these conflicts are brought to the courts. The aim of this study was to provide a descriptive and qualitative analysis of cases brought to the French courts.

Methods: We conducted a retrospective national observational study. All identified cases of emergency recourse to the judge in the context of LST limitation decisions in France between 2005 and 2022 were included.

Results: Seventy-six cases were investigated by the judge, with an increasing number over the years. The LST limitation decisions contested by the relatives were mainly decisions to withdraw treatment (78%) concerning patients with neurological injury (76%). The judge successively assessed the compliance with the legal decision-making process and the characterization of the inappropriateness of treatments. The latter was assessed by the judge using medical and non-medical criteria. In all, the medical decision was upheld in 29 cases (38%) and over-ruled in 20 cases (26%). Thirteen cases (17%) were finally settled out of court, and 14 patients (18%) died before the end of the investigation. The qualitative analysis highlighted opposing moral values and principles put forward by family members and physicians.

Conclusion: The growing incidence and deeply intertwined elements of these conflicts call for more policy and research to resolve them before they go to court.

Keywords: Case law; Conflict; End-of-life; Ethics; ICU; Life-sustaining treatment.